A. Problem Analysis

1. What was the problem before the implementation of the initiative?

In 2012, World Health Organization revealed that global population at risk of malaria were 3,400 million. Malaria has long been a global health threat particularly in remote forested areas of Africa and Asia. In 2010, according to WHO, there were 216 million cases of malaria with 655,000 deaths.
WHO, in 2005, urged member states to reduce the burden of malaria of at least 75 per cent by 2015. While there are significant more actions needed, resistance to artemisinin drug has emerged. The resistance found along the border areas of Cambodia, Myanmar, Thailand and Vietnam has threatened the gains made in malaria control, and its possible spread represents a major threat to the global malaria control.
The establishment of ASEAN Community in 2015 will increase border crossings and migrations of workers. Moreover, many of the temporary shelters will be closed down. These changes will result in increasing malaria transmission risk.
Under the malaria prevention and control program in Thailand, all malaria patients, received free of charge malaria microscopic diagnosis and treatment based on the national guideline. Malaria units in high risk remote areas for prompt diagnosis and treatment services have been set up. The integrated malaria management program has reduced the incidence. However, there were increasing trend of malaria incidence from 0.45 per 1000 population in 2005 to 0.57 per 1000 population in 2007. Along the 5,820 kilometers of Thailand borders, in 2011, there were 22,332,790 population with approximately 400,000 population of 19 varieties of ethnic groups. These are the most vulnerable to malaria. Mae Hong Son is one of the highest malaria incidence with the lowest Human Achievement Index (HAI) and the lowest household income (282 USD) compared to 1,530 USD of Bangkok Metropolitan reported by UNDP (2014). Distance from a pocket border village to a nearest local hospital can be 50 kilometers requiring up to 7 hours of walking through mountainous forest terrain without access to public road. The situation is worse during the rainy season, the peak malaria season.
Moreover, it is well known that selection of resistant microorganisms is exacerbated by inappropriate use of antimicrobials, which more often caused by incomplete or imperfect information for diagnosis in remote areas. A community diagnosis for malaria has become seriously needed. The accuracy and timeliness improvement of malaria diagnosis will allow Artemisinin-based combination therapies (ACTs) to target those who are in need of the therapy. This will help reducing over-consumption of antimalarial drugs as well as health services costs. Accurate and prompt diagnosis and treatment at the service point can save lives and income of the poorest population, control drug resistance and in turn bring down the malaria incidence to reach the regional goal.
The Department of Disease Control has clear vision and strong policy to improve government functions and human resources capacity building on malaria management in remote border areas through the use of Information Communication Technology (ICT) to solve the problem of distance and time and also to create the trust by using malaria telediagnosis on cloud.

B. Strategic Approach

2. What was the solution?

The Department of Disease Control (DDC), Ministry of Public Health is responsible for conducting research and creating innovation methods for malaria prevention and control efficiently. In 2010, the Office of Disease Prevention and Control 10 Chiangmai (ODPC 10) developed an initiative of the Webcam Connected Microscope (WebScope) and equipped at the Malaria Clinics in whole of Mae Hong Son province. WebScope is a modified webcam for microscope which had shown a result of accurate, timely and cost-effective malaria telediagnosis in Mae Hong Son. Director General of DDC, and his executive team had approved to move forward and promote the WebScope initiative as the best practice “Mae Hong Son Model” to be used nationwide in other remote border areas of 31 provinces.
Thailand has issued Thailand Information and Communication Technology Policy Framework (2011-2020) - ICT2020. The drive towards “smart health” indicates the need for development and innovation of ICT devices for smart medical devices and services. Under the ICT 2020 framework, Thailand Department of Disease Control addressed the strategy which focus on innovation and integration of services with good governance. The strategy of applying the “Mae Hong Son Model” are: Firstly, Information Technology equipment, Database System and Communication System Development. Secondly, Strengthening Information Technology and facility support. Thirdly, human resource and team capacity building. The introduction and integration of webcam connected microscope (WebScope) with internal communication system (On Cloud Computing Technology) had created and added value of this initiative. The objectives were to increase the effectiveness of malaria diagnosis in remote border areas as well as to build up human resource capacity and team building. The long run objectives of the initiative are targeting at reducing malaria incidence, mortality and controlling drug resistant malaria.
WebScope Malaria Telediagnosis on Cloud are integrated innovative systems. The first innovative system called “WebScope” was imitated from the routine quality control by saving a 4 image and one 5-6 minute video files of blood films using a modified webcam. The files are uploaded onto a centralized computer system at the end of each day. A microscopist at a reference laboratory re-examines the videos of blood films in accordance with established malaria QA protocol (10% negative and 100% positive). This system reduced the time of confirming blood film from an average of 21 days before implementation to less than 1 hour after implementation. Patients were followed up and received appropriate treatment within a day of reporting. The rapid response eliminates the “follow up loss” problem.
A modified webcam is installed on one eyepiece of a microscope and connected to a computer. The health personnel can examine a blood film on the computer screen and the image of the blood film can be recorded as a still photo or a video file. When a health personnel was uncertain about a diagnosis, the WebScope will be activated and connected to the internet for online consultation with an expert microscopist at the reference laboratory. During the consultation, the blood film is viewed live online by connecting images from the microscope to a computer using teleconference.
The second innovative system called “Internal Communication System” for database collection, analysis and sharing for malaria experts diagnosis. The initiative system uses applied Cloud Computing Technology for standard sharing of application (Software as a Service).
Target audiences are comprised of 1) all Thai and Non-Thai poorest people living in or moving across the remote border areas. 2) Malaria patients 3) Health personnel in Malaria Clinics 4) Malaria microscopic experts and 5) Village Health Volunteers.

3. How did the initiative solve the problem and improve people’s lives?

Based on the need of malaria community diagnosis, telediagnos by consultaion and confirmention by expert ,Webcam Connected Microscope (WebScope) was innovated in 2010. The device was tested and internet connected via public social network. This is the first time that simple tool, low cost technology combine with conventional method and information communication technology (ICT) are used to provide an effectiveness of health service for poor people along border remote areas. In addition, the initiative project has developed knowledge and skills of health personnel in service innovation based on ICT. It is also promoting access to exchange knowledge and experience in malaria microscope diagnosis through social networks. This allows health personnel and malaria experts in the whole country to share knowledge and experiences. It also boosts health personnel self-confidence and, very importantly, the confidence of patients in them and in the health services.

C. Execution and Implementation

4. In which ways is the initiative creative and innovative?

Based on the situation analysis using SWOT analysis (see attached file), the key strategies of project involved: an acceptable WebScope development appropriate for field use. there were two main issues related, firstly the specification of webcam, and secondly how to make it fix to the microscope perfectly. During 2009 – 2010, the processes of “Plan Do Check Act” were repeated several times. Based on the aforementioned survey of many existing webcams, difference models, difference companies were tested for the quality of image and with a number of variations of all malaria parasite species. Then a high quality image webcam was modified and tested in the field and brought back to the reference laboratory to be improved. In late 2010, the WebScope was completely innovated and tested in 5 malaria clinics compared with commercial camera microscope. The satisfaction survey of the WebScope was done after 8 months of trial. The feedback from all users was overall satisfactory. Health personnel was satisfied with the image of blood films taken by WebScope. There was a suggestion on modifying of an adapter to fix the eyepice of microscope and the extension cord. Field tests were then repeated to ensure that the reliability of WebScope was equal to direct examination of blood films under the standard microscope method, and potential users were satisfied with the innovative tool. The field health personnel and the deveopment team discussed and agreed upon a new procedure for using WebScope as well as a new monitoring and evaluation method.
Phase I, in 2011, WebScope was used in a malaria clinic in Mae Sarieng district. The health personnel and the development team in Chiang Mai monitored and evaluated WebScope by bimonthly teleconference calls and adhoc teleconference for difficult cases. At the end of each day, 10% of negative blood slides were randomly selected together with 100% of the positive blood slides, recorded as a video and sent to the reference lab. Within the day or later next day, an expert microscopist checked all the recorded files and sent the results back to the health personnel in the malaria clinic in Mae Sarieng. If there was any disagreement, the blood films were put online for discussion to reach a consensus decision. The patients with erroneous results were followed up for appropriate treatment.
Phase II, in 2013, the Department of Disease Control allocated budget for implementation of the initiative to cover all remote areas in Mae Hong Son province. The training course was setting up for 2 days to transfer technlogy and the ICT-system which had come from the agreement of health personnel and reference laboratory staff to achieve the goal of the project. The initiative system was implemented immediately after the training.
Phase III, in June 2014, whole of government had been started with the full support of the Department of Disease Control. The initiative was implemented in another 25 malaria clinics in other remote border areas of Thailand, including the 3 southern red zone provinces.
Phase IV, in October 2014, the initiative was also included in the work plan of the Department of Disease Control for improving program mangement of parasitic infection in remote border areas under the royal project of H.R.H Princess Maha Chakri Sirindhorn. Monitoring and evaluating the results of the initiative implemention in other parts of Thialand are in process.

5. Who implemented the initiative and what is the size of the population affected by this initiative?

The stakeholders involved in the implementation were the health personnel and malaria-diagnosis personnel who participated in the tool design and in learning how to use the tool and information technology. The medical technologists at the reference laboratory created the tools and set up the two modes of ICT-system of quality control.
The Strategic Planning Committee and Executive Board Funding Committee of ODPC 10 allocated a part of the budget for implementation of the initial project. Executive Board Committee of the Department of Diseases Control (DDC), Ministry of Public health also allocated the grand budget for implementation of WebScope in all remote malaria clinics (45 sites/ 350 health personnel). All 8 Offices out of 12 Office of Disease Prevention and Control and malaria clinics across the country participate. Other key stakeholders were local governments, primary schools in border areas, border patrol police schools, community leaders, village health volunteers, malaria patients and their families as well ethnic groups and migrant workers. Their major roles in participation and contribution to the initiative project were providing information on malaria prevention and control, close monitoring of drug compliance in malaria patients especially children, pregnant women and the elderly.
Moreover, patients were able to view the analysis taking place and provide their feedbacks. They contributed the time to answer questionnaires by a satisfaction survey. Importantly, the private sector and people in the city who had more opportunity (privilege group) to contribute budget for solar cells and computers to malaria clinics in remote border areas. This was an important issue which made the project feasible for expansion to other remote areas of the country.

6. How was the strategy implemented and what resources were mobilized?

In terms of financial, the cost of WebScope was 4,000 Baht (124 USD) per piece. The initial investment for this initiative were composed of startup costs for one site approximately 90,000 Baht (2,790 USD). Equipment and investment costs were comprised of microscopes 60,000 Baht (1,860 USD), computers 20,000 Baht (620 USD), and miscellaneous materials, e.g. blood film preparation set, stationery and waste disposal setup 6,000 Baht (186 USD).
In addition, the operating expenses 60,000 Baht (1,855 USD) per year, were for implementation, monitoring and evaluation of the initiative. Salaries of 2 health personnel involved in the initiative, 4,320 Baht per month (134 USD), partial salary of the expert microscopist was 3,000 Baht (93 USD) per month. Malaria clinic and office maintenance was 1,800 Baht (56 USD) per month and blood slide preparation was 5 Baht (0.15 USD) per patient.
The initiative project had one site at the malaria clinic in Mae Sarieng. The health personnel was trained on the use of the WebScope and programme. On-site visit of the team from the reference laboratory costed around 20,000 Baht (620 USD). These costs were comprised of per diem and accommodation for 3 staff, gasoline and materials include WebScope and document printing. The implementation of 10 sites was needed to save time and traveling budget. The expense which was supported by the Department of Disease Control for training including per diem, local transportation, accommodation and document printing was approximately 5,000 Baht (156 USD) per person.
For technology investment, cost of setting up the Cloud Computing Technology was 450,000 Baht (14,062 USD) and 10% for maintaining of the system. The cost of 3 Computer Servers was 900,000 Baht (28,125 USD). Cost of the Storage unit was 750,000 Baht (23,437 USD) The software was an in-house developed one which was very small.

7. Who were the stakeholders involved in the design of the initiative and in its implementation?

The most successful outputs of the Webcam Connected Microscope (Webscope) for trusted malaria telediagnosis on cloud in remote border areas of Thailand are as follows :
Firstly, from the Mae Hong Son Model, use of the innovative WebScope evidently showed the reduction time for accurate diagnosis of malaria from 21 days to 10 minutes. Moreover, the Webscope showed 100% reliable results compared to direct examination by microscope. The use of Webscope together with public social network was very simple that health personnel in remote areas can be trained and do it immediately after returning to their malaria clinics (70 health personnel in 17 units). In addition, they can also further teach and coach their colleges to use this innovative medical device. They also clearly showed satisfaction, acceptance and enthusiasm. The feedback from satisfaction survey among the users was 99%.
Secondly, the system improvement by connecting WebScope with Internal Communication System on Private Cloud for malaria telediagnosis could be expanded to all malaria clinics in remote border areas under management of the eight out of twelve Offices of Disease Prevention and Control (45 sites, 350 health personnel). A preliminary survey among the system users showed 95 % in satisfaction, utility, usefulness and applicability for other disease pathogens.
Thirdly, the implementation of the initiative has been fostering leadership, human resource capacity, knowledge management and collaborative networks in malaria management at national level down to community level in all border provinces.
Fourthly, the WebScope Malaria Telediagnosis initiative had been publicly recognized and had won several distinct awards including National DDC Conference (First Place Winner 2012) Thailand Public Service Awards (First Place Winner 2013), Thailand Research Expo (Silver Awards 2014) and National Annual MOPH Conference (First Place Winner 2014).

8. What were the most successful outputs and why was the initiative effective?

The Webcam Connected Microscope (Webscope) for Trusted Malaria Telediagnosis on Cloud in Remote Border Areas of Thailand has been monitoring and evaluating in three elements, i.e. technology, people and process. Tracking of key data for monitoring and evaluation is done through record keeping, regular reporting and periodic surveys.
Daily online monitoring has been carried out to improve performance and solve working problems in accuracy of malaria diagnosis and quality of blood slide preparation.
Monthly report for monitoring of crucial data such as number of visitors, number of malaria patients, type of infection, source of infection and patient nationality, drug compliance and number of deaths.
Bi-annually site visit monitoring for improvement of individual performance work problems solving, reliability and accuracy checking of the WebScope tool and response time from the malaria experts back to the malaria clinics in remote areas.
Periodic teleconference calls between project managers, information technology personnel, malaria experts, and health personnel in malaria clinics was set up to monitor personnel performance, provide technical supports and develop solutions for the obstacles of the implementation.
Questionnaires survey to evaluate work performance and users’ satisfaction. The results of the questionnaires were compiled and analyzed by the development team at the reference laboratory. Then, modifications of the WebScope and the operating computer programs were made according to the analysis of the field tests and questionnaires.
The impact indicators are annual incidence per 1000 mid-year population among Thai and non-Thai and refugees in temporally shelters, drug compliance, in vivo drug resistance, recovering rate, mortality rate and cost effectiveness. Data is collected monthly, analyzed and used for planning and improving the system as well as expanding of the project for malaria clinics in other remote border areas with high malaria incidence.

9. What were the main obstacles encountered and how were they overcome?

The main obstacle of this project is the internet system which sometimes fails due to bad weather. The solution is recording blood films in digital format and video files for later review and uploading when the internet signal returns. In an area with no electricity, installment of solar panels for power to run computers and internet modems are necessary.
Secondly, team building is very important to set up the environment of working in such a harmonious environment. At the beginning of the project, miscommunication between health personnel and malaria experts occurred very often. The project manager and team have to take action very carefully to maintain an enthusiastic workforce. The problem solving tactics were providing of clear mission and a sense of purpose, recognition of the contributions from both sides and facilitating to get their jobs done. In addition, the feeling of being checked, and the “us and them” barriers must be broken down.
Thirdly, there are generally inadequate numbers of malaria microscopic experts. However, the online system of this telediagnosis initiative has provided opportunity for establishing and networking of the expert team nationwide.
Last but not least, although the innovative tool (WebScope) is inexpensive, but to implement the initiative in other new sites, expensive high performance computers and internet are needed. On the other hand, IT infrastructure on Cloud Computing Technology allow effective sharing of IT equipment through Visual Desktop and Visual Server. In this way, inexpensive general performance computer can be used.

D. Impact and Sustainability

10. What were the key benefits resulting from this initiative?

The key benefit resulting from this initiative was that people in remote rural areas received accurate and timely malaria diagnosis and treatment. The length of time was drastically reduced from an average of 21 days to 10 minutes. In Mae Hong Son Model, during 2013 – 2014, there were 24,314 people enrolled and 1,133 were malaria positive that received appropriate medical services within 1 hour. Other benefit was the people trust that resulted in 100% of these patients completed drug compliance and returned for drug resistance monitoring. It was also noticeable in the reduction of people that were hospitalized. The number of severe malaria patient at hospitals was decreased from 47 to 1 compared to after the initiative implementation. The number of malaria deaths fell to zero. The numbers of students with malaria infection in Mae Hong Son province reduced from 769 to 243 cases. One hundred per cent of people were satisfied with the services at malaria clinics and were confident with the results. In addition, the patients who come to the malaria clinic not only received diagnosis and treatment from health personnel but also from malaria microscopic expert via the system. It was no doubt that the initiative project had increased the equity of access to health services for the people in remote border areas. In socio-economic aspect, poor malaria patients had less financial burden and return to work or school quicker than before.
The new tool had helped increasing health personnel’s confidence in performing and providing the health care services. The WebScope allowed individual patient to see image of parasites on blood slides, provided opportunity for patient education and treatment instructions. As a result, patients’ adherence to treatment improved which in turn leaded to a better health care outcome and drug resistant malaria prevention and further spread of malarial infection. The initiative project had improved the effectiveness in monitoring and evaluation of the treatment of malaria patients in remote areas, which was important in detecting any drug resistance that might occur.
The new malaria telediagnosis had resulted close cooperation in malaria management at community level. This will be one of the key success factors to achieve malaria elimination goal.
Lastly, the initiative had been applied to use for other pathogen microscopic diagnosis, e.g. intestinal parasites, blood parasite. It was likely also that the initiative system can be applied for bacterial diagnosis.
Benefits are about people. It's not whether you have the forms filled in or whether the checks are written. It's whether the people are cared for when they're sick, and helped when they're in trouble.

11. Did the initiative improve integrity and/or accountability in public service? (If applicable)

The WebScope Malaria Telediagnostic on Cloud has been in line with the royal duties of H.R.H Princess Maha Chakri Sirindhorn who never abandoned the people in remote border areas. It has been also publicly recognized and supported by many institutes due to its high resolution imagery, affordability, portability, and user friendliness. The initiative has gained policy support from the Department of Disease Control to be used for malaria and expanded for other parasite control in remote areas of Thailand. The department also allocated budget for implementing the initiative in other parts of Thailand, including the three southern border provinces of Thailand where access to care can be difficult.
The WebScope has been transformed from a simple diagnostic tool for malaria to a multipurpose diagnostic and teaching tool. It is currently being used in several training courses domestically and internationally. For example, the WebScope was used in an international malaria training workshop conducted by the Department of Biochemistry, Faculty of Medicine, Chiang Mai University. The Department of Diseases Control and the ODPC10 in Chiang Mai used WebScope in the training of post-graduate students from the University of Utah and University of New England, and used it in an international course on malaria prevention and control for officers and medical doctors from South East Asia and Africa supported by the Japan International Cooperation Agency (JICA) training program. In addition, a study of antimalarial drug resistance at ODPC10 in Chiang Mai employed the WebScope to record images of parasite growth at different incubation periods. It was also used for diagnosis training and research on drug resistant malaria at the Malaria Training Center, Bureau of Vector Borne Diseases, DDC, MoPH, and in the Department of Biochemistry, Faculty of Medicine, Chiang Mai University. At ODPC7in Ubon Ratchthani, Ubonratcha Thani province, the WebScope was used to examine sizes of insecticide droplets.
Scaling up of this initiative to national level is attainable with minimum cost in equipment and training. Transferability of the WebScope to neighboring countries is high due to its affordability, minimal training requirements, and ease of maintenance.
Lastly, WebScope is designed with future modification in mind. When computer technology and the quality of webcams improve, WebScope can be modified accordingly. The instruction for WebScope comes with the anticipation of future modification. The compartments of WebScope are general materials that are cheap and easy to find.

12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)

A critical experience for our team is that health personnel enthusiasm was the result of transparent, credible, and inspiring organization. It is in effect, a "reason for being" that translates for health personnel into a "reason for being there" which goes above and beyond money.
Lessons learned included the importance of first obtaining initial buy-ins from health personnel prior to implementation of the project. Cooperation from the health personnel is necessary since they are required to attend additional trainings to learn a new device and to follow appropriate operating and maintenance procedures. Through encouragement and positive feedback with positive outcomes of patients due to timely and accurate malaria diagnoses, health personnel learn to consult on-line, exchange ideas and problem solving with colleagues at reference labs. Timely and on-going communications between field health personnel at their Malaria Units and colleagues at the regional reference laboratory are crucial to the success of the project.
The initiative system allow coaching and online training of health personnel. It is a great motivator for the health personnel in remote borer areas. Online learning is also an effective mentoring tool between experts and health personnel in remote locations. Additionally, the patients also involve in the project, not only health personnel.
Malaria patients are diagnosed quickly and accurately and this can lead to correct malaria treatment. Although it is too early to measure the effect on malaria incidence reduction in such a short time, at least the initiative has substantially increased the accuracy of malaria microscope diagnosis and established a mutual benefit alliance of health personnel and microscopists.
Recently, there is an epidemic of the Ebola virus in Africa, where there is a high incidence of malaria. Patients infected with malaria and Ebola have very similar symptoms. Therefore, accuracy and timely diagnosis of malaria can rule out Ebola. Malaria patients can receive appropriate treatment and lives can be saved. Last but not least, the WHO estimated that 600 million people are infected with malaria and there were 627,000 malaria deaths worldwide in 2012 (uncertainly interval, 473,000 – 789,000), if we can implement our initiative it would have reduced the number of unnecessary deaths from malaria.
Based on our experiences and lessons learned, the WebScope Malaria Telediagnosis on Cloud should be implemented towards the malaria elimination goal achievement as well as strengthening of other priority diseases.